Understanding Depression: What We Know and What You Can Do About It

305 Pages·2002·1.08 MB·English

by  J. Raymond DePaulo

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Understanding Depression
(cid:1)
WhatWe Know and
WhatYou Can Do About It
J. Raymond DePaulo, Jr. M.D.
Leslie Alan Horvitz
John Wiley & Sons, Inc.
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I dedicate this book to my wife, Joanne Althoff,
to my mother, Mrs. Catherine DePaulo,
and to my daughters,
Mrs. Marianne Plant and Mrs. Margaret Kottke.
Copyright © 2002 by J. Raymond DePaulo. All rights reserved
Published by John Wiley & Sons, Inc., New York
No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means, electronic, mechanical, photocopy-
ing, recording, scanning, or otherwise, except as permitted under Section 107 or
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This title is also available in print as ISBN 0-471-3955-20
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Contents
Acknowledgments v
Foreword vii
Introduction 1
Part One:Understanding Depression
1 The Experience of Depression 9
2 The Experience of Mania: Bipolar Disorder 24
3 Who Is at Risk for Depression? 36
4 Recognizing Depression in All Its Forms and Guises 46
5 Stressful Events: When People Get Depressed 64
Part Two:Unraveling the Secrets
6 What Do We Know About the Brain? 74
7 Genes and Depression: The Fateful Inheritance 88
8 Hormones, Headaches, and Heart Attacks 95
Part Three:Depression and Mania and
Destructive Effects on the Whole Person
9 Depression, Manic Depression, and Relationships 106
10 Destructive Behavior 120
11 Facing up to Suicide 132
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iv CONTENTS
Part Four: Treatments for Depression
12 Getting Help for Depression 157
13 Making the Diagnosis Is the First Treatment 164
14 Medical Treatment 173
15 The Different Kinds of Drugs 182
16 Psychotherapy: Treating the Person 196
17 ECT, Light, and Other Medical Treatments 209
18 Alternative Treatments 220
19 Hospitalization: A Guide for Patients and Families 229
20 Getting Back to Normal 236
21 Going Forward 251
Appendix A: Insurance 262
Appendix B: Helpful Organizations 266
Appendix C: Helpful Books 273
Glossary 277
Bibliography 284
Index 289
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Acknowledgments
I would like to thank several people who made this book possible and
made it better than it would have been otherwise. First I want to thank
Ms. Jane Nevins, editor in chief of the Dana Press for providing the
editorial guidance for this project; and William Safire, Chairman of
the Dana Foundation and the Dana Press for giving me this wonder-
ful opportunity for a second book on depression. Working with
patients who are ill with depression or manic depression is one of the
most rewarding jobs in medicine. With the possible exception of
delivering a baby, there is no professional experience more satisfying
than seeing a patient emerging from an episode of severe depression.
I happily work every day for this. And since it is in one sense all I do,
it is also the only topic today that I could write a book about. I also
thank Mr. Tom Miller and Ms. Lia Pelosi at John Wiley & Sons for
their editorial work.
I also want to thank Mr. Les Horvitz, who has helped me immea-
surably to make a message into a book. We met for nearly three hun-
dred hours and worked on our own much longer than that to
produce this manuscript. Les was an active, engaged collaborator,
reading the hundreds of source papers I selected; going over them
with me to prepare for a chapter and accepting my interpretation of
them (for better or for worse). Les came from New York to Baltimore
regularly to discuss with me the book and all its extensions. I held
stacks of papers in my hand, lead him through one-on-one seminars
of two to three hours duration, and then loaded the papers and chap-
ters into his satchel and asked him to return with the draft. His
patience and sage advice were a great help and I am grateful to him.
I also wish to thank at the top of this acknowledgment Ms. AnneE.
Phillips, who will be entering medical school this fall. Anne came to
work with me as a research assistant shortly after getting her master’s
degree in biomedical technology. She came at a time when I had
been doing much more editing than writing. Her talent and my weak-
nesses as an essayist created her major work, namely, helping to get
me back to writing again. It involved her reading new papers and
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vi ACKNOWLEDGMENTS
picking ones I should read. She edited out the duplications and basic
flaws in my writing, developed a bibliography, and helped access
expert advice as needed. She became a one-woman Kiretsu. Without
Anne there would be no Understanding Depression.Thank you.
I owe particular thanks to my chairman Paul McHugh M.D., for
being a wonderful mentor and strong supporter for twenty-six years
and to Kay Jamison Ph.D., for her encouragement and enough ideas
for three books as well as a foreword for this one. I take courage from
both their work as teachers of students and advocates for patients and
families. I thank Barbara Schweizer R.N., B.S., for her support and
unflagging friendship; and I thank Dr. Virginia Willour Ph.D. and
Ms. Jennifer Coughlin for reviewing the manuscript and giving help-
ful advice. I also want to acknowledge my colleagues who have helped
me develop ideas included in this book: Michael Kaminsky M.D.,
John Lipsey M.D., Karen Swartz M.D., Melvin McInnis M.D., Sylvia
Simpson MPH, M.D., Dean MacKinnon, M.D., Todd Cox M.D., James
A. Potash M.D., and Frank Mondimore M.D.. I want to thank the
many dedicated staff members on Meyer 4 including Trish Caruana
LCSW-C, Sharon Walsh Esterbrook C.O.T., Rachel Tajenstein, M.S.W.
and the nursing staff especially Chris Boyle RN and Deborah Brown
RN. I also want to thank the members and staff at DRADA (Depres-
sion and Related Affective Disorders Association) especially, Sallie
Mink, RN, Wendy Resnick, RN, Cathy Pollock, Anne Hilgartner,
Vicki, Paulette Finck, and the members of the Roland Park and Tim-
onium DRADA Family Support Groups for their advice and helpful
insights. I also want to acknowledge and thank all of the research
assistants who have kept our genetics research going and who have
provided countless valuable questions and critiques: Krista Vishio,
Jennifer Chellis, Erin Miller, Brandie Craighead, Katie Aman, Gwen
Walker, Colleen Clarkin, and Lizza Gonzales. To Jen Coleman, who
did so many tasks so that I could get started in this effort, thank you.
I acknowledge and thank Mr. Ken Heyman for the medical illus-
trations contained in the figures. I wish to acknowledge that about
four chapters were derived from the “Grand Rounds” discussions I
have presented over the last ten years at Johns Hopkins.
To my patients and their families, thank you for encouragement,
advice, and for agreeing to see a better future when faced with today’s
conspicuously fallible enterprise.
Lastly to my wife, Joanne Althoff, who has been patient and
encouraging, and critical only when I asked her to be one of my
“readers.” I offer heartfelt thanks.
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Foreword
Depression, for those who have it, is a painful and inextricable illness;
for those who do not, depression is simply inextricable. Depression
and manic-depression (bipolar disorder) are common illnesses in
adolescents and adults and not uncommon ones in children. Suicide
is one of the leading causes of death for those dealing with depres-
sion in virtually all age groups. Yet, where there should be open and
informed discussion, there is a terrible silence. Depressive illnesses
are highly treatable but most who suffer from them never receive any
kind of treatment at all. Of those who do, most receive far less than
ideal care. We know a tremendous amount about the symptoms,
causes, and treatments of depression, but there remains an indefen-
sible gap between what clinicians and scientists know and what the
people who are depressed know. This is unfortunate and potentially
dangerous.
Understanding Depression, written by Dr. J. Raymond DePaulo, Jr.,
a Professor of Psychiatry at the Johns Hopkins School of Medicine, is
an excellent bridge between medical science and the sufferer. It pre-
sents in a direct and compelling way the most important things that
patients and their families need to know about the symptoms of
depression and mania; what depression and mania feel like to those
who experience them; and what the best and most effective pharma-
cologic and psychotherapeutic treatments are. Dr. DePaulo covers
the advantages and disadvantages of different treatment options, as
well as medication side effects and how best to manage them. He also
deals with the co-occurrence of anxiety, alcohol, and drug use, and
other common problems that affect the treatment outcome of
depression. Dr. DePaulo’s approach to the clinical management of
mood disorders is based on taking a long-term perspective on the ill-
nesses, rather than focusing on just the presenting episode of depres-
sion. This is critical to providing excellent clinical care, and it is a
perspective strongly supported by what we know scientifically and
clinically about depressive illnesses.
I have been privileged to work and teach with Dr. DePaulo at
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viii FOREWORD
Johns Hopkins for the past fifteen years. He is, without doubt, one of
the best clinicians and clinical teachers I have ever known. His under-
standing of depression is deeply grounded in science, and his treat-
ment approach is characterized by compassion, pragmatism, subtlety,
and an obvious affection and respect for the many thousands of
patients he has so effectively treated.
None of us has a choice about becoming depressed. We do, how-
ever, have a choice about becoming informed about our illnesses.
Understanding Depression is the best place to begin the process of
becoming informed.
Kay Redfield Jamison, Ph.D.
Professor of Psychiatry
The Johns HopkinsSchool of Medicine
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INTRODUCTION
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A Clinician’s View of Depression
and Manic Depression: Progress,
Ignorance, and a Promise
This book presents my experience—as a psychiatrist who has seen in
consultation, teaching, research, and treatment settings some 8,000
people—with clinical depression and manic-depressive illness. I’ve
also had a chance to meet thousands of other patients and their fam-
ilies in a variety of forums around the country including support
groups and educational meetings.
Since many books have been written about depression you may
be wondering for whom this book is written. First, it is for people who
think that they may be suffering from depression or manic depres-
sion (bipolar disorder) and who want to know more about it. Second,
it is for people who have already been diagnosed with depression (or
bipolar disorder) and are in treatment, but who want to understand
more about it in order to deal with it more successfully.
Third, I am writing for people who are concerned about a family
member or loved one who may be in treatment or who is not receiv-
ing any medical care but probably needs it. Those of you in this cate-
gory are very likely looking for advice on how to go about persuading
the individual who might be depressed to go for help. On the other
hand, you may be in a situation in which you feel shut out of the com-
munication loop (as happens too often) between a family member
and the doctor. It is very difficult to know what you can do to help (or
what you shouldn’t do) when you don’t know how the treatment is
actually progressing or what outcome can reasonably be expected. I
hope this book will help you to participate more effectively as a
patient or as a family member. Some readers may be oriented toward
self-help, which is truly important as a part of all treatment plans.
Nothing in treatment in my experience is more powerful than the
efforts of patients and families who understand what they can do.
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